Basic Information
| Provider Information | |||||||||
| NPI: | 1669473955 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 LONGWATER DRIVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817924136 | ||||||||
| FaxNumber: | 7818786750 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 WOOD ROAD | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | 7818786750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 11/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 71590 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3093158 | 05 | MA | MEDICAID | 110051363A | 05 | MA | MEDICAID |